Ethical concerns facing abortion researchers in restrictive settings: the need for guidelines

Keywords:

• abortion
• ethical dilemma
• abortion laws
• Africa

Introduction

Several African countries criminalise induced abortion, and the issue is hotly contested. Nevertheless, induced abortion occurs as frequently in countries that ban abortion totally (with only minor exceptions) as in countries without restrictions.¹ The difference between countries where abortion is legal and those where it is illegal is the proportion of abortions that are unsafe. For example, in Kenya, where the legal environment is restrictive, Mohamed et al. reported that 75% of all induced abortions are unsafe.² The World Health Organization³ defines unsafe abortion as any procedure for pregnancy termination performed by either a person who lacks the requisite skills/training or in an environment without the minimum medical standards, or both.

The criminalisation of abortion and hence fear of prosecution, coupled with stigma, pushes people seeking induced abortions to proceed with the utmost secrecy.⁴ Researchers investigating questions on abortion and post-abortion care in the sensitive African context often encounter disturbing revelations of immense ethical concern. Addressing those issues in an ethically acceptable way without compromising the research participants engenders dilemmas that require finesse to resolve.⁵

In our abortion research at the African Population and Health Research Center (APHRC), we have encountered participants who reportedly have acted in ways that are at least unacceptable or, at worst, criminally liable. Some participants have revealed information that places us in a precarious position on how to respond without endangering the participants, having also guaranteed them privacy and confidentiality before the interview began. Such revelations can result in ethical dilemmas, particularly when researchers have to deal with disclosures of illegal behaviour.

In this commentary, we share our experiences conducting research on abortion (spontaneous and induced and safe and unsafe) and post-abortion care, highlighting situations where participants have revealed information to us that has been ethically challenging. We have undertaken studies on diverse aspects of abortion in African countries including Burkina Faso, Kenya, Liberia, Nigeria, Sierra Leone, and Zambia. We feel it is critical to share the ethical dilemmas we have encountered in conducting abortion research to facilitate a broader public discourse on the issues and the possible development of regional and national guidance that offers specific support to researchers investigating criminalised and stigmatised behaviour.

Experiences that challenged our ethical standards

In one study (an evaluation of an intervention that we have not yet published to prevent any interference with the programme), we worked with mystery clients to assess the availability, accessibility, and quality of care in providing medical abortion drugs in pharmacy outlets in Kenya. We trained data collectors to pretend to be pregnant and present in selected outlets seeking termination of pregnancy. These mystery clients reported sexual harassment by some pharmacy vendors, including their insistence on having sex before “helping” with medical abortion products, or touching the clients’ breasts and genitals while performing “physical examinations” to confirm pregnancy status.⁶ In another study, a provider reported in an in-depth interview, where confidentiality had been guaranteed, that he takes advantage of girls seeking abortion care by having sex with them before “helping” them.⁷ In areas of research where participants were not at risk of punishment for engaging in illegal behaviour, reporting the revelation of abuse or unethical practice would not present such challenges. However, in the case of abortion, researchers reporting such patient violations would risk inadvertently exposing the abortion-seeker to prosecution, persecution, and societal stigma.

In one study in Liberia conducted between 2021 and 2022 (national dissemination of the findings is scheduled for March 2023), focusing on estimating the national incidence of induced abortion, a post-abortion care patient told our interviewers that she had a spontaneous abortion because her husband violently beat her and kicked her in the stomach at five months gestation. She vehemently begged our interviewers not to say anything and reminded them of their assurance of confidentiality as she did not want her husband to find out she had told anybody about the situation and did not want her husband arrested. We have also encountered situations where providers in Kenya told our interviewers that they often demand sex instead of financial payment when girls cannot afford the exorbitant prices that the vendors quote for the services.

Why are providers taking advantage of people seeking abortions?

In all the countries where we have conducted abortion research, the law criminalises abortion with a few exceptions under emergencies, such as the health and life of the pregnant woman being endangered. Those known or suspected to have induced abortions also face stigma. Therefore, people seeking abortion do so under the strictest secrecy. At the same time, studies (e.g., Omondi et al., 2022⁸) have shown that when people want to terminate unwanted pregnancies, they are willing to do anything to achieve that. Providers understand women’s desperation to terminate unwanted pregnancies and the utmost need for secrecy to forestall stigmatisation. They also know that women and girls do not have adequate knowledge of how the abortion process works, especially medical abortion. Some unscrupulous providers, therefore, take advantage of the situation, reminding abortion-seekers that induced abortion is illegal, and underlining their own risk in “helping” them terminate the pregnancies. For their “sacrifices”, they demand compensation beyond financial payment, including sexual intercourse. They are brazen about this because they know that women cannot incriminate themselves by reporting the assault to the police or opening themselves to ridicule and stigma by telling relatives and friends. They abuse women and girls because they know they can get away with it.

How have we handled these situations?

We report these adverse events to the ethical review committees in all situations. However, our experience suggests that these committees may not always be well-equipped to address such challenges. As far as we know, ethical review committees in Kenya and other countries where we have undertaken abortion research provide guidance for reporting adverse events in biomedical research (e.g. adverse drug reactions). The adverse event reporting forms only mention medical events, omitting behavioural and social issues. Additionally, we have considered reporting the cases to the police for action, but this line of action is problematic. Reporting to the police could place the field workers who interviewed the provider at serious risk of retaliation because they would be required to come forward as witnesses. The provider may remember the person who interviewed him and seek to harm them. Further, the cases may boil down to a “she said, he said” situation, not likely to lead to any appropriate action against the abuser. Moreover, reporting the cases to the police would inadvertently expose the women sexually violated by providers to criminal prosecution for securing illegal abortions.

Because of concerns about breaching confidentiality agreements, we reached out to regulatory bodies that license health professionals to bring attention to issues of sexual misconduct by healthcare workers. However, we found that there is no anonymous procedure for reporting incidents of malpractice or misconduct by pharmacists, pharmacy technicians, or other staff working in pharmacies or drug outlets. Instead, when we wrote to these bodies, they asked us for specificities, including the names of the people involved, the name of the pharmacy or drug outlets, and the dates. We worried that this information might expose the mystery clients to harm and danger and decided not to pursue this strategy.

We know that for United States Government-funded projects, researchers can obtain a certificate of confidentiality when conducting research that may lead to criminal or civil legal proceedings against research participants.⁹ A certificate of confidentiality protects the researcher from being forced to disclose the identity of a research participant if such revelation would harm them criminally, civilly, or otherwise. But we have not found evidence of such guidance in the African countries where we have conducted abortion research. Ethically, researchers are bound to report cases of child abuse irrespective of the assurances of confidentiality they gave the research participant.

Given the lack of appropriate guidance on managing these challenges, we reached out to some partners to see if they have guiding documents or have had such experiences in the past. One international partner informed us they previously encountered a similar situation in a mystery client survey and reported it to the institutional review board (IRB). But, as in our case, the IRB had limited experience handling the situation. Some have suggested working with human rights civil society groups to mount a “sting” operation and catch the abusers in the act to facilitate prosecution. Some have also offered well-reasoned advice to include a warning in the informed consent information that we would report cases of abuse irrespective of our assurances of confidentiality. As a result, we have included a standard text to that effect in our informed consent information sheet. This standard message would allow us to report cases of abuse to the appropriate agencies, including women’s rights groups, women’s protection institutions, and the police or other security services, where necessary. This reportage would help researchers address their dilemmas and protect research participants from further abuse without necessarily breaching privacy and confidentiality rules.

What is the way forward?

There is an urgency for researchers and research institutions in Africa to have actionable guidelines to facilitate the safety of researchers, data collectors, research participants, and other affected parties. National agencies responsible for setting standards and guidelines for ethical and responsible research (e.g. National Council of Science, Technology and Innovation—NACOSTI—in Kenya) can lead the development of a guiding document. Training researchers and international review boards on the appropriate mechanisms for reporting and handling such dilemmas would improve the ethical conduct of research. Further, a regional or global safeguarding document outlining steps for reporting and protecting those who report malpractice during research, especially sexual and reproductive health research, could help identify and address cases of sexual violence. The safeguarding document could provide avenues for anonymous reports and tips to the appropriate bodies responsible for addressing such issues.

Implementing continuous training of healthcare providers on responsible and respectful sexual and reproductive health care is paramount. All professional health associations must develop anonymous reporting structures for potential victims to register complaints against erring officers. In Kenya, even the Medical Practitioner and Dentists Board can facilitate reporting by making the form (https://kmpdc.go.ke/for-public/) on their website for reporting malpractice anonymous.

The regulatory body responsible for professional health providers (e.g. the medical associations) can focus on continuous provider training, especially on dignified and respectful care of all patients, irrespective of the conditions patients present. Values clarification and attitude transformation training exercises to prepare providers for safe abortion and post-abortion care services may be valuable. Beyond training, a mechanism that identifies and reprimands erring providers, including revocation of licenses and prosecution, may serve as a deterrent to others.

The provision of comprehensive sexuality education to equip girls and women with information on preventing pregnancy can reduce girls’ and women’s exposure by equipping them with the tools necessary to extricate themselves from abusive or potentially abusive healthcare processes, and to facilitate reporting abuses when they happen. It would also be important to expand the availability and access to reliable contraceptives and remove the requirement for parental or guardian consent to providing sexual and reproductive healthcare services to adolescents.

Further, liberalising abortion laws or creating more options and exceptions for women to access safe and legal abortion would increase the number of willing providers who regard their abortion services as a duty and not as “help”. With that, women will demand the services, which must be provided with a respectful and standard quality of care without abuse. Moreover, this will improve the willingness of women who experience abuse during care to report cases without fear of criminal prosecution or persecution.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Swedish International Development Agency [grant number 12103].